詳細(xì)中醫(yī)問(wèn)診單 英文版-

1、1, the general situation:Gender: Age:Marital Status: Height: Weight :Disease process and the main symptoms: (Required, the more detailed the betterWestern disease:Please select from the following parts of the body condition (delet the cases dont haveFacial: red, yellow, white, black, greenEye: pupil

2、 gray; white eye pupil green, yellow; has bloodshot eyes, petechiae, a raised, black spots, blue or green skin below the eye, swollen eyelidsTongue: hypertrophy, thin, sharp or the tongue red, slippery and wet, with scalloped, dry, greasy, yellow coating, white coating, there are cracks, tendons and

3、 varicose sublingualTeeth: tooth pain, activity,Ears: tinnitus, hearing loss, itching, pain, out of the liquid from ears, eye: dry, dim, dizziness, tearing, pain, itching,color of the eyes color: color green, yellow, with or without bloodshot? Have petechiae? Have black spots? Have dryness, Mouth: b

4、itter, dry, sour, tasteless, ulcers, sleep salivationNose: blocked, runny nose, do not distinguish smells, dry, Pharynx: dry, pain, itching, difficulty swallowingHead (pain, dizzy, swelling, numbness, wood, faint, heavy in the head, two temples, occipital, frontal, full head:Neck (stiff, pain, sour,

5、 heavy, bulging, location? When heavier? Awake? Activities work?Chest: full, nausea, swelling, pain, bone pain, heat, coldBreast: swelling, pain, hyperplasia, lumps,sides of body: swelling, pain, heat, cold,Abdomen: swelling, full, pain, hard,Vulva: Swollen, swelling, pain, heat, cold, such as fever

6、, bulge, contractureHeart: feel upset palpitations, panic, tight, pain, cold, hot, Heartbeat fastStomach: swelling, pain, full, Pantothenic, feel cool, hotHead: pain, dizzy, hemp, slow-witted, faint, heavyHands: cold, hot, dry, sweating, numbness, trembling,fingers pain, a pain, atrophy,Waist: tired

7、, heavy, pain, swelling, cold, heat,Legs: pain, tired, heavy,torpidity, slow-witted, swollen, swelling, stiff, soft, cool, hot,Knee: pain, swelling, cold, hot, soft, bone pain, weakness,Foot: pain, swelling, numbness, slow-witted, weakness, cool, hot, 3, select the following items corresponding to t

8、he physical condition (Required -Drinking: more, less, prefer cool water, prefer heat water, prefer warm water, like sour, spicy delight, bitter delight, salty delight, sweet delightEat: more, less, like rice, nodo delight, like porridge, like greasy, tired of greasy, fried food, BBQ, coldSleep: mor

9、e, less, insomnia, sleep a lot, much dreams, easy to wake upSkin condition (without rash, rash color? Skin color? Without swelling, lumps? Texture, boils, local color, whether itch? Pain? Skin temperature cool or hot?Fecal: dry, wet, sticky, constipation, incontinence, color black, yellow, white, ru

10、nny diarrhea, once a day, several times a day, a few days onceUrine: much, less poor,Incontinence, yellow, white, more often, less frequentSexual: Yes, no, more, less, impotence, premature ejaculation, masturbation, had an abortionMenstruation: earlier than date, later than date, excessive, less, da

11、rk, red, pale, thick, Dilute, blood clots, dysmenorrhea, spilledleakageLeucorrhea: there is, None, more, less, white, yellow, fishy, foul What are the symptoms feels usually - fever, sweating, cold, afraid of the wind, heat intolerance, asthma, , cough, shortness of breath, phlegm, hiccups, vomit in

12、verse nausea, diarrhea, blood in the stool, blood in urine, vomiting blood, nosebleed , bleeding gums, irritability, limb tremor, limb stiffness, weakness, fatigue, lightheadedness, talkless , addicted to lying, tired of lying, hemiplegia, hot and cold Alternately, keep low-grade fever, swollen lymp

13、h nodes, sternum tingling, standing feel tired , varicose veins, feel bone empty, , bone fever, nocturnal emission, premature ejaculation, impotence, infertilityOften emotions - joy, anger, depression, thinking, sadness, fear, palpitationsBlood pressure, heart rate. Be sure to fill out.Gynecological

14、 diseases interrogation : In addition to the above, please add the following condition:1, your menstruation? Age at menarche: the past, the menstrual cycle: the amount of bleeding and bleeding Duration: Have clot or not: dysmenorrhea Level: 2, vaginal discharge situations: * shape, volume, color, od

15、or, genital itching, abdominal pain,3, motherhood times: (including abortion, medical abortion4, the following references selected according to your situation pelvic mass should indicate time of onset, the pain, what size of the medical examination showed that the size of the mass, In case of abdomi

16、nal pain, please describe the onset time, pain intensity, frequency, onset incentives or other symptoms, abdominal pain parts, associated symptoms,Pregnancy history: age of first pregnancy, motherhood whether the frequency and time of maternal infection, obstructed labor, bleeding and other abnormal

17、ities. What Western medicine examination ? results?6, What examinations have you took? (as detailed as possible: blood, urine, liver and kidney function, x ray examination, b ultrasound, endoscopy, CT, magnetic resonance imaging, etc. How to treat previously, the days spent:Drugs used (traditional Chinese medicine, Western medicine: Effect:Diet and lifestyle 1, food Whats for breakfast ( food : 2, whas for lunch: 3, Whats for dinner: